OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Teacher Questionnaire; Request for Administrative Information

OMB 0960-0646 · SSA.

OMB 0960-0646

When determining the effects of a child's impairment(s), SSA obtains information about the child’s functioning from teachers; parents; and others who observe the child on a daily basis. SSA requests teachers complete the SSA-5665, Teacher’s Questionnaire to obtain a report on the child’s daily overall functioning, comprehension, and known medical conditions throughout the school day. SSA requests the school administration to complete the SSA-5666, Request for Administrative Information, to obtain formal testing results, other teacher reports, therapy progress notes, individualized education program documents, and other records of a child's educational aptitude and achievements. The respondents are teachers, educational administrators, and other education personnel.

The latest form for Teacher Questionnaire; Request for Administrative Information expires 2029-09-30 and is listed under ICR 202607-0960-002.

View the official OMB control history on Reginfo.gov.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form SSA-5666 Request for Administrative InformationForm and Instruction
Form SSA-5665-BK (Elect Teacher QuestionnaireForm and Instruction
Supporting Statement - 0646 (Final).docxSupporting Statement A
Addendum - 0646 (Final).docxSupplementary Document
SSA-5666 (Administrators) Form and Instruction
SSA-5666 (Administrators) Other-Cover Letter
SSA-5665-BK (Teachers) Form and Instruction
SSA-5665-BK (Teachers) Other-Cover Letter

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202607-0960-002 Revision of a currently approved collection 2026-07-31
202008-0960-016 Revision of a currently approved collection 2020-12-09
201703-0960-017 Revision of a currently approved collection 2017-07-03 Approved without change
201404-0960-008 Revision of a currently approved collection 2014-07-28 Approved without change
201304-0960-006 No material or nonsubstantive change to a currently approved collection 2013-08-06 Preapproved
201103-0960-016 Revision of a currently approved collection 2011-07-14 Approved without change
200804-0960-003 Revision of a currently approved collection 2008-07-21 Approved without change
200801-0960-001 No material or nonsubstantive change to a currently approved collection 2008-01-23 Approved without change
200505-0960-004 Revision of a currently approved collection 2005-05-20 Approved without change
200409-0960-016 No material or nonsubstantive change to a currently approved collection 2004-09-29 Approved without change
200405-0960-018 No material or nonsubstantive change to a currently approved collection 2004-05-24 Approved without change
200402-0960-012 No material or nonsubstantive change to a currently approved collection 2004-02-20 Approved without change
200202-0960-005 New collection (Request for a new OMB Control Number) 2002-02-21 Approved without change

OMB Details

SSA-5665-BK (Teachers)

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Information collection instruments
FormNameElectronic accessType
Form SSA-5665-BK (Electronic)Teacher QuestionnaireFillable Fileable SignableForm and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.